ASRM PAGES

Using family members as gamete

donors or surrogates
The Ethics Committee of the American Society for Reproductive Medicine
American Society for Reproductive Medicine, Birmingham, Alabama

The use of intrafamilial gamete donors and surrogates is generally ethically acceptable when all participants are fully informed and
counseled, but arrangements that replicate the results of true consanguineous or incestuous unions should be prohibited, child to parent
arrangements are generally unacceptable, and parent to child arrangements are acceptable in limited situations. Programs that choose
to participate in intrafamilial arrangements should be prepared to spend additional time coun-
seling participants and ensuring that they have made free, informed decisions. (Fertil Steril Use your smartphone
2012;98:797803. 2012 by American Society for Reproductive Medicine.) to scan this QR code
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C
ollaborative or third-party re- sister providing eggs for a sister or parentage for resulting children (16).
production is sometimes consid- a brother donating sperm to a brother. Although limited data have been col-
ered by couples or individuals It may also occur intergenerationally, lected regarding the attitudes, motiva-
who themselves lack the healthy eggs, as when a mother gestates her daugh- tions, and experiences of donors and
sperm, or uterus they need to have ter's embryos or a father provides recipients in such arrangements (79),
children. Gamete donation is a recog- sperm to his infertile son. no information on the impact on
nized method to enable infertile cou- Some possible collaborative repro- children is available, so it is im-
ples without healthy eggs or sperm to ductive arrangements that involve possible to judge the seriousness of
conceive. Surrogacy is indicated when family members are listed in Table 1. these problems.
the uterus is absent or unhealthy, This table and the following discussion The Ethics Committee in this docu-
when the female partner for medical involve primarily rst-degree relatives. ment concludes that the use of gamete
reasons cannot gestate a pregnancy, The use of second-degree relatives such donors and surrogates who are family
or in cases of a single male or same- as cousins, nephews, or aunts and un- members is in many cases ethically ac-
sex male couple utilizing assisted re- cles raises similar issues, but for sim- ceptable, but that some cases raise seri-
productive technologies (ART) to have plicity these arrangements are omitted ous problems and should not occur. To
a child. The surrogate may provide the from the table and most of the subse- distinguish these cases, providers of
egg as well as the uterus (traditional quent discussion. ART should pay special attention to
surrogacy), or she may undergo trans- While familial collaboration may aforementioned issues of consanguin-
fer of embryos that were created from offer advantages over the use of non- ity, risks of undue inuence on deci-
the eggs and sperm of the infertile cou- family donors and surrogates, it may sions to participate, and the chance
ple (gestational surrogacy). also present unique problems. These that the arrangement in question will
Collaborative reproduction usually problems include issues of apparent cause uncertainty about lineage and
involves anonymous or unrelated incest (i.e., sexual relations between parenting relations.
known individuals, but some couples two closely related individuals) or con-
prefer to involve a family member sanguinity (i.e., marriage and repro-
in the arrangement. This may occur duction between individuals who are EXTENT OF FAMILIAL
intragenerationally between siblings closely related genetically), undue in- COLLABORATION IN
or cousins of similar ages, such as a uence to participate, and confused REPRODUCTION
There is a paucity of data about the
Received June 20, 2012; accepted June 22, 2012; published online July 24, 2012. use of familial gamete donors and sur-
Correspondence: American Society for Reproductive Medicine, 1209 Montgomery Highway, Birming-
ham, AL 35216 (E-mail: asrm@asrm.org). rogates in assisted reproduction. With
regard to intragenerational gamete do-
Fertility and Sterility Vol. 98, No. 4, October 2012 0015-0282/$36.00
Copyright 2012 American Society for Reproductive Medicine, Published by Elsevier Inc.
nation, a 1992 survey of members of
http://dx.doi.org/10.1016/j.fertnstert.2012.06.046 the Society for Assisted Reproductive

VOL. 98 NO. 4 / OCTOBER 2012 797

ASRM PAGES
TABLE 1
Potential intrafamilial collaborative reproductive arrangements among 1st degree relatives.
Donation type Arrangement
I. Sperm donation Brother-to-brother
Brother-to-sister
Brother-to-sister (sister uses
donated eggs)
Father-to-son
Father-to-daughter (daughter
uses donated eggs)
Son-to-father
II. Ovum donation Sister-to-sister
Sister-to-sister-in-law
(brother's wife)
Daughter-to-mother
Mother-to-daughter
III. Traditional surrogacy Sister-for-sister
Sister-for-brother
Daughter-for-mother
Mother-for-daughter
Ethics Committee. Family members as donors. Fertil Steril 2012.
798
Resulting genetic and social
relationships of offspring
Social paternal uncle is genetic
father; other relationships
unchanged
Rearing mother is also genetic
and gestational mother;
social uncle is genetic father
Rearing mother is gestational
mother, but has no genetic
relationship to offspring; social
uncle is genetic father; some
cousins are half-siblings; most
other relationships unchanged
Social paternal grandfather is
genetic father; rearing father
is genetic half-brother
Social maternal grandfather
is genetic father
Rearing father is genetic
grandfather; offspring's social
half-brother is genetic father;
genetic paternal grandmother is
usually rearing father's ex-wife
Social aunt is genetic mother; some
cousins are half-siblings; most
other relationships unchanged
Social aunt is genetic mother
Rearing mother is genetic
grandmother; offspring's social
half-sister is genetic mother;
rearing mother's ex-husband
is usually genetic maternal
grandfather
Social maternal grandmother is
genetic mother; offspring is
half-sister of rearing mother
Social maternal aunt is genetic and
gestational mother; social
cousins are half-siblings; most
other relationships unchanged
Social aunt is gestational
and genetic mother
Rearing mother is genetic
grandmother; half-sister is
genetic and gestational mother
Social grandmother would be
genetic and gestational mother;
offspring is rearing mother's
half-sibling
Comments
Most acceptable intrafamilial
sperm donation
Gives strong impression of incest,
but not strictly illegal because
neither sex nor marriage are
involved; should be prohibited
because gametes from a
consanguineous relationship
are combined (sister is genetic
mother and brother is genetic
father)
Gametes are not from
consanguineous relationship;
not prohibited, but may create
impression of incest or
consanguinity
Acceptability may depend upon
attitude of female partner;
ASRM guidelines discourage
donors >40 y because of
concerns for new mutations
A proposal for this arrangement
involving a divorced daughter
who lived with her father has
been discussed (6); gives strong
impression of incest
Usually second marriage for father;
signicant concerns for undue
pressures on son; should be
discouraged
Probably most common and most
accepted arrangement
Should be prohibited because
gametes from consanguineous
relationship are combined; gives
strong impressions of incest;
never reported
Usually second marriage for mother;
concerns for coercion of
daughter are signicant;
should be discouraged
Not reported; age of mother would
make success unlikely
Examine relationship of surrogate
to her sister's husband
Should be prohibited because
gametes from consanguineous
relationships are combined;
gives strong impression of
incest; never reported
Concerns for undue pressure are
signicant; examine relationship
of daughter to stepfather
Not reported; age of mother
would make success unlikely
Continued
VOL. 98 NO. 4 / OCTOBER 2012
 Fertility and Sterility

TABLE 1

Continued.
Resulting genetic and social
Donation type Arrangement relationships of offspring
IV. Gestational surrogacy Sister-for-sister Genetic relationships unchanged;
social maternal aunt is
gestational mother
Sister-for-brother Social aunt is gestational mother.
Genetic relationships
unchanged
Mother-for-daughter Genetic relationships unchanged;
social maternal grandmother
is gestational mother
Daughter-for-mother Genetic relationships unchanged;
social half-sister is gestational
mother
Daughter-for-father Genetic relationships unchanged;
social half-sister is gestational
mother
Ethics Committee. Family members as donors. Fertil Steril 2012.
Comments
One of rst reported cases of
gestational surrogacy
Gives impression of incest,
but gametes are not from
consanguineous relationship
Health of older mother should
be considered; should ensure
daughter is not obligated
to mother
Not reported; age of mother
would make success unlikely
Not reported; gives impression
of incest

Technology (SART) found that almost all North American
ART programs accepted sister-to-sister ovum donation, but
only 43.3% would allow brothers to be sperm donors (10). A
1998 survey of ART clinics found that 60% of clinics would
accept sperm from brothers while many more would accept
sisters (90%) and friends (80%) as egg donors (11).
The number of requests for intergenerational familial
gamete donation and the number of these procedures per-
formed is also unknown. The 1992 survey of SART members
found that intergenerational gamete donation was allowed in
39.3% of 52 oocyte donation programs and in 26.4% of 60
programs using sperm donation. Child-to-parent donation
(37.5%) was more often permitted than parent-to-child dona-
tion (28.6%) in oocyte donation programs. The converse was
true in programs utilizing sperm donation, with 26.4% allow-
ing parent-to-child and 18.9% allowing child-to-parent do-
nation (10).
There are no specic data on intrafamilial surrogacy. Sur-
rogacy arrangements are much less common than gamete do-
nation. They may be expensive, complex, and restricted by
law in some states. Cases of intrafamilial surrogacy do occur
as originally seen in a sister-for-sister gestational surrogacy
using donor sperm reported in 1988 (12). Soon thereafter,
the case of a South African woman carrying triplets for her
daughter and son-in-law was highly publicized (13), as was
the case of an American woman providing gestational surro-
gacy for a daughter who could not carry a pregnancy (14).
THE CASE FOR FAMILIAL COLLABORATION
Couples faced with infertility who need or choose to use a do-
nor or surrogate face a novel set of issues and relationships
when an unrelated or an anonymous donor is used. The rela-
tionships associated with familial collaboration are also
novel, but may be easier for some persons to resolve. The rea-
sons for seeking a familial donor or surrogate are varied.
While some individuals are willing to use an unrelated or
anonymous donor or surrogate, others would much prefer
nding third-party reproductive assistance in the family.
For some couples or individuals, gametes from family mem-
bers may be preferred because they are thought to preserve
the family's genetic heritage and kinship, or reduce the risk
of genetic or sexually transmitted infections. For others,
a family member may be selected as a donor or surrogate to
speed the process or to reduce costs.
Familial gamete donation ensures that some portion of
the infertile person's genes will be passed to the offspring,
thus maintaining a kinship tie that would be lost if an unre-
lated donor were used. In one of the few reports about known
sperm donors, family involvement was chosen so that the in-
fertile male could feel a genetic closeness to his child (15).
Thus, using a sibling's gametes will result in rearing a genetic
nephew or niece who has some, but usually less than 50%, of
the infertile person's genes. Intergenerational donations, such
as father-to-son sperm donation or daughter-to-mother egg
donation, also involve the transfer of some of the recipient's
genes to the offspring. The importance of maintaining genetic
kinship may be an important reason some people nd anon-
ymous ovum or sperm donors unacceptable. Family members
who donate may also view the process favorably. They con-
tribute additional progeny to their kindred while also contrib-
uting to the well-being of a kin relation.
An important factor in selecting a familial donor or sur-
rogate is reduction of costs and waiting times. Reproductive
technologies are expensive, often not covered by insurance
plans, and in some areas may require long waits for certain
procedures. The involvement of a family member may in
some cases result in signicant nancial savings for the infer-
tile couple, and enable some to have a procedure that would
not otherwise be available to them. An oligospermic man
may seek sperm donation from his identical twin rather
than pay for in vitro fertilization with intracytoplasmic sperm
injection (ICSI) because he considers that his twin brother's
sperm are identical to his own. A sister providing eggs is un-
likely to request payment and can avoid a long waiting period
for an anonymous egg donor. Similarly, paid surrogacy is

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ASRM PAGES
legally prohibited in some jurisdictions and is prohibitively
expensive where allowed, so many couples may turn to family
members for assistance.
Intrafamilial organ donation may provide a useful paral-
lel to intrafamilial gamete donation, although substantial
differences exist. The successful practice of intrafamilial
donation of kidneys, bone marrow, and even liver segments
is well established and represents a vital alternative to organ
donation from non-related living or cadaveric donors. Organ
donation carries greater risk than gamete donation, but it may
be life saving and is widely accepted. Although procreation
may seem to be a less pressing need than treating end stage
organ failure, having children is highly valued and can
greatly increase personal and family welfare. Because altru-
ism within families is especially valued, allowing family
members to accept the lesser risks of gamete donation or sur-
rogacy in service of the fertility goals of close family members
should also be ethically acceptable. Assessing or judging mo-
tivations such as love, devotion, loyalty, and duty within an
intimate family may be best left to those family members,
as long as providers involved in these arrangements have
paid due regard to informed consent, free decision-making,
and the welfare of the child-to-be (16).
CONCERNS ABOUT INTERFAMILIAL
COLLABORATIVE REPRODUCTION
Intrafamilial collaborative reproduction raises ethical con-
cerns distinct from concerns raised by other donor or surro-
gate arrangements. Can a donor or surrogate closely tied to
and perhaps dependent on the recipient couple make a free
and fully informed decision? What are the consequences of
the unusual resulting relationships on the donor or surrogate,
donor-conceived persons, and rest of the family? What are the
consequences of the creation of new genetic relationships that
would be otherwise impossible? The lack of information re-
garding these important questions illustrates the knowledge
gaps that should be the subjects of formal investigation. In
the meantime, providers should not hesitate to share these
concerns in the course of counseling their patients.
Impermissible Collaborations
Laws against incestuous sexual relations and consanguineous
marriages are ways in which society regulates reproduction.
Sexual relations, marriage, and reproduction between two
closely related individuals have long been taboos, because
of concerns about the risk of birth defects and genetic diseases
as well as concerns about social disruptions and conict
which such relations could raise. Laws banning sexual rela-
tions and marriage between certain classes of individuals
would not ban gamete donation or surrogacy involving these
same individuals because no sexual relations or marriage
would have occurred. The Committee, however, strongly be-
lieves that fertility practices should not assist or participate
in gamete donation or surrogacy arrangements in which the
child would have the same genetic relationship to the partic-
ipants as would children of incestuous or consanguineous
unions between rst-degree relatives (including adopted
and stepchildren).
800
Under this approach, a sister may provide eggs for a sister
or a brother sperm for a brother, but a brother may not provide
sperm to fertilize a sister's eggs or a sister provide eggs to be
fertilized by a brother's sperm. Similarly, a father should not
provide the sperm to replace that of his daughter's infertile
husband. Nor should a mother provide eggs to replace those
of her son's infertile wife. A different situation arises when
a sister provides the eggs for her brother's infertile wife to
be inseminated by a donor, or a brother provides sperm to
a sister to use with an anonymous egg donor. Neither case du-
plicates the results of incest or consanguinity, so should not
be barred. However, such arrangements may give the appear-
ance of incestuous or consanguineous unions, and the poten-
tial implications of such appearances should be addressed in
counseling.
Similarly, persons aware that a woman is gestating the
embryo of her mother and stepfather may conclude that sex-
ual relations have occurred. In cases of daughter-to-mother
ovum donation, the donor's contribution to her stepfather's
child may also be perceived as incestuous. (Stepfather/
stepdaughter sexual relationships are generally considered
incestuous and are subject to civil penalties in most states).
Although this report focuses on rst-degree relatives, the
Committee notes that restrictions on fathers as sperm donors
to daughters with infertile husbands should also bar the
daughter's paternal or maternal uncles from serving as a
sperm donor to her. Similarly, the maternal or paternal aunts
of a son with an infertile wife should not serve as an egg
donor for the wife of that son if he would also provide the
sperm. Sexual relations or marriage between rst cousins is
not illegal in some states. Rather than address the different
combinations that might arise from gamete donation or sur-
rogacy among rst cousins, we note that a recent review
found that procreation between rst cousins added a 1.7%
to 2.8% risk of major malformations and genetic diseases to
a background risk of 3% to 4% (17).
Undue Inuence and Autonomous Decision-
making
A major concern in familial collaborative reproduction is pro-
tecting the autonomy of the contributing donor or surrogate
from manipulative or undue inuences by family members
who would benet from their participation. Those risks may
be greater with intergenerational than with intragenerational
collaboration, but could occur with both arrangements. For
example, a daughter may feel obligated to donate eggs or
be a traditional surrogate to her remarried mother because
she is still nancially or emotionally dependent on her.
Some individuals may exert great inuence over their
siblings and persuade them to be donors against their better
judgment.
The risk of undue inuence may depend on the physical
and emotional closeness of the donor or surrogate to the re-
cipient couple, the maturity of the participating family mem-
bers, and other issues such as nancial dependency. Some
emotional distance may be necessary for the donor or surro-
gate to make a free and fully informed decision. This may
be especially difcult to achieve when a parent requests
VOL. 98 NO. 4 / OCTOBER 2012

a child's involvement in collaborative reproduction. Some
writers argue that because undue inuence cannot be elimi-
nated in child-parent relationships, a truly free decision to
participate in such cases of collaborative reproduction is
impossible (4).
The concerns that emotional or nancial coercion,
whether overt or unconscious, make daughter-to-mother
or son-to-father donations extremely difcult, if not im-
possible, to assess. For example, the complicated intrafamilial
relationships in the case where a stepdaughter has a shared
genetic connection with her stepfather through the donor-
conceived child independent of her mother raises serious con-
cerns. Furthermore, consideration of the donor-conceived
person's feelings and reactions as well as the donating
daughter's or son's children's interests need to be considered.
A donor-conceived child would be both genetic halfsibling
and aunt or uncle to the donor's children and the emotional
impact of this relationship is not understood. Due to these is-
sues the Committee concludes that in such cases risks are
raised to an unacceptable level, and as a matter of principle
child-to-parent donation should generally be prohibited.
It may be easier to achieve emotional distance and min-
imize undue inuence in other circumstances. For example,
a couple might request help from a cousin who lives in
another city and will have very little contact with any off-
spring. A father might decide to donate sperm to his son as
an extension of his parental role in meeting his children's
needs. Similarly, a mother who volunteers to be a gestational
surrogate for her daughter may view her involvement as
just another way to help her children achieve their goals in
life. In each case, the free and informed decision-making of
all participants must be assured. The risk of undue inuence
in intrafamilial organ donation is well recognized and is at
least as great as in intrafamilial reproductive collaboration.
Screening and counseling procedures developed to ensure
free and fully informed consent in intrafamilial organ dona-
tion, such as separate interviews and counseling of the in-
volved parties, are transferable to intrafamilial reproductive
situations.
Emotional Harm to Donor or Surrogate
Donors and surrogates in these intrafamilial arrangements
are exposed to emotional as well as physical risk. They may
expect special recognition from family members and others
for their efforts, but, instead, may be met with negative feel-
ings from many sources. Gamete donation and surrogacy are
not always looked on favorably by the general public or even
by other family members. If the procedures are not successful
in establishing a pregnancy, the infertile individuals may di-
rect anger at the donor or surrogate. If the child has a genetic
or birth defect, the donor or surrogate may blame herself or
himself or feel blamed by others; the long-term stresses asso-
ciated with a disabled child may be projected upon the in-
volved donor or surrogate.
Familial donors and surrogates may also have to undergo
genetic and infectious disease screening procedures, includ-
ing a six-month quarantine of sperm (18), which they may
not have expected and may nd objectionable. They may
VOL. 98 NO. 4 / OCTOBER 2012
Fertility and Sterility
also contend with the reactions of their own partner to their
involvement in the reproductive goals of a family member.
In one survey on known sperm donors including family do-
nors, 25% said the donation process led to a deterioration of
the relationship between the infertile couple and the donor
(15). This deterioration was related to the attitude of the do-
nor's partner, who had not been involved in the decision to
donate sperm.
Donors or surrogates may have difculty detaching
themselves from the children, especially when they have a
genetic link to the offspring of the arrangement. Yet, if the
parties have been careful in drafting and signing the neces-
sary documents to clarify legal parenting relationships, the
familial donor or surrogate will have no more legal parenting
or visitation rights than would an unrelated known or anon-
ymous donor. If conict among family members develops, the
situation could be especially painful for familial donors and
surrogates who may no longer be allowed to contact or visit
a genetically related child.
Impact on Offspring and Family Relationships
A primary concern is the potential impact of these arrange-
ments on children and families. Children can never consent
to the circumstances of their conception, even if they later be-
come aware of them and suffer from conicts or disruptions
that those circumstances bring. Persons entering into these
relationships should be especially sensitive to the social and
psychological complications that might ensue and take spe-
cial care to ensure that the child's welfare is protected.
Knowledge of the actual genetic relationships among the
participants could contribute to a profoundly altered view of
identity and family relationships (Table 1). Gamete donation
to a sibling means that the rearing parent is actually the ge-
netic aunt or uncle of the child, while the social aunt or uncle
is the genetic parent. In daughter-to-mother egg donation, the
offspring's gestational and rearing mother is also the genetic
grandmother. The donor is the genetic mother but is regarded
socially as the half-sister. The offspring has two maternal
grandfathers, the rearing mother's father and the rearing
mother's ex-husband. After father-to-son sperm donation,
the offspring's rearing father is his genetic half-brother and
the rearing grandfather is his genetic father. When a son or
daughter's gametes are used to help a parent conceive, the
offspring will usually have 25% genetic material from the
parent's former spouse. Medical and mental health profes-
sionals have raised concerns about the emotional conse-
quences that could occur (3, 4), and have emphasized the
need to pay special attention to the psychological needs of
children born of such relationships.
Larger societal concerns are raised by these arrangements
as well, because they may create new genetic relationships
never before possible. A woman could not otherwise gestate
a child conceived with her daughter's egg, for whom she is
the genetic grandmother. The offspring's genetic lineage be-
comes very confusing, further complicating the concept of
the family. The importance of the goal to preserve genetic
linkages may be questioned when the reproductive arrange-
ments become so extraordinary and complex.
801
ASRM PAGES
Although new genetic relationships may be created
from these family collaborations, the impact of these few
families on society would probably be minimal. Some writers
have argued that families resulting from reproductive tech-
nologies such as gamete donation actually mirror our soci-
ety's norms (19, 20). Complicated family arrangements are
often the products of divorce and remarriage. Most third-
party reproduction involving family members should not be
alarming in today's climate. These arrangements will add
complexity to only a small number of families in a society
with an increasingly complex concept of the family.
SCREENING, COUNSELING, INFORMED
CONSENT, AND LEGAL COUNSEL
The Committee nds that for the use of familial donors and
surrogates to be ethically acceptable, special care must be
taken to ensure that the interests of all parties are protected.
To do so, providers should be prepared to spend more time
screening and counseling participants compared to anony-
mous or unrelated known collaborative reproductive arrange-
ments. Requests for intergenerational gamete donation or
surrogacy are especially challenging.
To enhance the likelihood that familial collaboration will
be a positive experience, the involvement of professionals
representing multiple disciplines, including physicians,
nurses, and counselors, should be anticipated for a thorough
assessment. Adequate time is essential to evaluate proposals
for these arrangements. Prospective donors or surrogates
should have a physician whose responsibility it is to care
for them and be their advocate. Clinics not equipped to pro-
vide these services should choose to refer patients to a center
where these services are offered.
Programs should strongly recommend that prospective
participants, including partners of donors and surrogates, un-
dergo psychological counseling by a professional experienced
in surrogacy or gamete donation (18). These visits should fo-
cus attention on how participants will cope with the unique
aspects of the proposed arrangement and on the conse-
quences for the prospective child.
The potential emotional consequences to the child should
be a primary concern when discussing these arrangements. If
children are informed of their intrafamilial conception or ges-
tation, specialized counseling may be desirable as they get
older, especially for arrangements that give any impression
of incest or result in altered views of identity and family
relationships. The ethical issues related to disclosure are dis-
cussed in more detail in the ASRM ethics guideline Informing
offspring of their conception by gamete donation (21).
The process of obtaining informed consent from the
requesting individuals and the donor or surrogate should
involve a thorough discussion of potential physical and
emotional risks to all parties and to the anticipated child.
Clinicians should assure that the decision to be a gamete do-
nor or surrogate has been voluntary and free from manipula-
tive and undue inuence. They should also offer prospective
donors and surrogates the option of being excluded as
participants without other family members learning of their
reluctance to participate. Financial incentives, including
802
direct and indirect payment and inheritance, should not be
so substantial that they become inducements that may lead
the prospective donor or surrogate to discount the risk associ-
ated with the procedure (22).
Current standards governing anonymous sperm and
ovum donation and surrogacy should be followed in regard
to screening of the proposed sperm or ovum donor for infec-
tious and genetic diseases. Semen specimens should be frozen
and quarantined according to published guidelines for sperm
donation (18). In many cases the delay that results from
this quarantine will discourage a couple from pursuing intra-
familial sperm donation. When sperm or egg donation is
chosen to prevent a certain genetic disease, careful genetic
counseling should be done before intrafamilial gamete dona-
tion is allowed.
An important part of the informed consent process is in-
forming the participants of the legal parenting relations that
will result from the arrangement. Documents signed, together
with the law of the state or jurisdiction in which the familial
collaboration occurs, concerning gamete donation and surro-
gacy will determine the legal parenting relations among
recipients, donors, and surrogates and resulting children.
State law will also determine whether children are the heirs
of the donor or surrogate or the recipient-rearing parents
when an intrafamilial participant dies without a will. Partic-
ipants in these arrangements, including partners of donors
and surrogates, should seek independent legal advice from at-
torneys with specic expertise in third-party reproduction to
determine their legal rights and duties in entering into these
relations.
Finally, in certain cases requests should be denied imme-
diately. Due to potential undue inuence by a parent, pro-
grams should not allow minors, as dened in each state,
to participate in these arrangements. Gametes from rst-
degree consanguineous relationships (e.g., brother-to-sister
without donated eggs) should never be used together to initi-
ate a pregnancy. Providers should participate with care in in-
trafamilial arrangements that give the impression of incest or
improper consanguinity (see Table 1), though exceptional
cases where adequate provision for those risks have been
made may be acceptable.
CONCLUSIONS AND RECOMMENDATIONS
All ART programs should develop policies and procedures for
dealing with requests for the use of family members as
donors or surrogates. Although programs have no obligation
to provide such services, the Ethics Committee nds that
many intrafamilial reproductive arrangements, including
both intragenerational and some intergenerational arrange-
ments, will be ethically acceptable and satisfying, but that
others should be rejected on grounds of consanguinity or be-
cause of lack of free, informed consent. The most problematic
requests are usually a parent requesting the involvement of
his or her child in gamete donation or surrogacy. In these
cases, and when the assessment reveals consistent concerns
about undue pressures on the prospective donor or surrogate,
or about unhealthy family dynamics, the program is ethically
justied in denying access to these procedures.
VOL. 98 NO. 4 / OCTOBER 2012

Acknowledgments: This report was developed by the Ethics
Committee of the American Society for Reproductive Medi-
cine as a service to its members and other practicing clini-
cians. While this document reects the views of members of
that Committee, it is not intended to be the only approved
standard of practice or to dictate an exclusive course of treat-
ment in all cases. This report was approved by the Ethics Com-
mittee of the American Society for Reproductive Medicine
and the Board of Directors of the American Society for Repro-
ductive Medicine.
The following members of the ASRM Ethics Committee
participated in the development of this document. All Com-
mittee members disclosed commercial and nancial relation-
ships with manufacturers or distributors of goods or services
used to treat patients. Members of the Committee who were
found to have conicts of interest based on the relationships
disclosed did not participate in the discussion or development
of this document.
Paula Amato, M.D.; Robert Brzyski, M.D., Ph.D.; Andrea
Braverman, Ph.D.; Jean Benward, L.C.S.W.; Andrea Stein,
M.D.; Bonnie Steinbock, Ph.D.; Bruce Wilder, MD., M.P.H.,
J.D.; Richard Reindollar, M.D.; Dolores Lamb, Ph.D.; John
Robertson, J.D.; Judith Daar, J.D.; Leslie Francis, J.D.; Mark
Gibson, M.D.; Senait Fisseha, M.D., J.D.; Steven Ralston,
M.D.; Mark Sauer, M.D.; Monique Spillman, M.D.; Robert
Rebar, M.D.; Sean Tipton, M.A.
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